QA vs. QI: The Battle Royale

In my last column, I told the story of how I first came to test my assumption that clinical peer review would be forever antithetical to quality improvement. Today, I’d like to outline for you the characteristics that differentiate a QI model for peer review from the dysfunctional, legacy QA model. The QI model frames peer review as a quality improvement activity, not only to improve the process itself, but to better support the effort to improve clinical performance and patient safety. It’s a battle for the hearts and minds of the medical profession that will affect nursing as well: the way we know vs. the way it could be.

The QA and QI Models Compared
Dimension QA Model QI Model
Focus Outliers Shift the curve
Identify Substandard care Learning opportunity:
System & Individual
Determine Competence Performance
Inputs Single case Multiple cases
Case Finding Generic screens Self-reporting
Method Judgment Measurement
Process Variable Standardized
Reliability Low Good
Leverage Point Expert opinion Aggregate data
Orientation Reactive Proactive
Cultural Drivers Fear, Punishment Trust, Fairness, Collegiality
Data Capture "Leveling" against care standards Multiple elements of performance
Relation to Hospital QI Process Isolated Highly interdependent
Governance Laissez faire Attentive
Accountability for Improvement Low High
Ultimate Process Outputs Corrective action System improvement
Recognition of clinical excellence
Performance feedback
Net Effect Culture of Blame Culture of Safety

Paradoxically, for all the fear it has generated, the QA model has done little to generate accountability for improvement. This is probably because the threshold for action is so high that only the most egregious situations are addressed. In part, this stems from the poor reliability of the typical approach case review which looks only at whether the standard of care was met. It also confuses performance with competence.

The QI model holds that a single case review speaks primarily to situational performance. It deploys a more reliable, balanced methodology that is suited to data aggregation and seeks to extract whatever can be learned to improved clinical performance.

The QI model continues to evolve. For example, case identification has long been a problem. Most programs still rely on inefficient generic screens. Recognizing the sad reality that physicians always know when an adverse event occurs, but are often blocked from sharing and learning for fear of recrimination, I added case identification via self-reporting. The federal protections of the Patient Safety and Quality Improvement Act of 2005 offer a simple mechanism to make it safe to self-report. I’ll share more about that in a future column. Meanwhile, evaluate your own peer review program against the QI model at:

The theme of personal and organizational learning turns out to be critical to safety culture and quality improvement. Peer review is only part of the story.

Coming Next: 3 Modes of Learning

Marc's signature

Marc T. Edwards, MD, MBA

President & CEO

QA to QI

An AHRQ Listed Patient Safety Organization